The reconfiguration of hospital services in England

Debate about the right size, function and distribution of hospital services has recently come to dominate discussions about NHS reform, but the issues are far from new.

When the NHS was established in 1948, it nationalised a patchwork of hospitals which had previously been run by local authorities and voluntary organisations.

Attempts by governments to rationalise the number and size of hospitals in line with contemporary medical wisdom have been made a few times since, with at best partial success.

The current Labour government launched its first major set of policies on the future organisation of hospital services this time last year.

The health and social care white paper Our Health, Our Care, Our Say published at the end of January 2006 set out proposals to shift less complex procedures out of hospitals and into community settings such as GP surgeries, nurse-led units and home-based support programmes.

The government said that this shift was desirable because the public want more convenient services, and was now possible thanks to developments in medical technology. The government also believes care in these settings will prove to be cheaper than providing the same procedures in hospital, though evidence on this is mixed.

In the government's vision, these devolved services are to be complemented by large, regional centres of excellence offering state-of-the-art facilities and expert staff to perform more complex operations. The development of such centres is supported by clinical evidence which shows that for some surgical operations, the higher the volume performed by a hospital department, the better the outcome is for patients.

Reconfiguring hospital services is controversial, since it often involves some institutions being closed. Such closures are consistently met with opposition from local communities who have strong loyalties to local hospitals or concerns about how far they will have to travel to access services in the future. The case for change may not be properly communicated to the public and anyway clinical evidence on what is safe does not always point policy in a clear, single direction. Necessary discussions about long-term cost-effectiveness can become entangled with short term concerns about budget deficits.

The logic of current government policy is that new community and regional specialist services will replace some services currently provided by district general hospitals. This will reduce demand for these services in hospitals, which could result in planned closures to some hospital services, or in extreme cases, to entire hospitals. If services aren't closed, but demand for them is met elsewhere, then as a result of the new 'payment by results' system - under which money follows patients and hospitals are paid for each treatment they provide rather than being given a lump sum - hospitals may experience a falling income, which may call into question whether they can continue providing services in the same way. The government's position implies that closures to parts or all of a hospital may be acceptable because the services will have been replaced by services which are of a higher quality and more convenient for patients, and which offer better value for money for the tax payer.

But there are a number of potential problems with all this. Firstly, local decisions by primary care trusts and strategic health authorities about how services should be provided are influenced by financial and other considerations in addition to central government policy; a service closure won’t necessarily be part of a grander programme to improve the quality of services in keeping with contemporary clinical evidence. Secondly, even if local NHS organisations followed government policy to the letter, evidence of whether the proposed changes will offer better care for patients and be more cost effective has yet to be fully established.

Financial deficits in some NHS organisations are forcing trusts to consider which services they continue to provide and which may no longer be financially viable. Although only a minority of trusts are in deficit, top-slicing of funding by strategic health authorities to help ensure that the service as a whole can record a balanced budget at the end of this financial year means that all NHS organisations will be feeling the pinch.

The full implementation of the European Working Time Directive will also make it harder for some hospitals to continue to provide medical cover 24-hours a day. From 2009, junior doctors won’t be able to work for more than 48 hours a week (including time spent on call), almost half the 72 hours maximum in force before the Directive’s implementation began in 2004. Hospitals are heavily dependent on junior doctors to provide medical support for patients over night, so a substantial reduction in their hours will mean hospitals have to employ more junior doctors or get consultants to provide more night cover. This will be particularly difficult for small hospitals.

Both financial pressures and pressure from the European Working Time Directive to reorganise staffing rotas may act as a catalyst for NHS organisations to look at how they can work more efficiently, which could lead to positive changes. The pressures may also lead to short-term decisions which result in the reduction or closure of some services.

Even if services are genuinely reconfigured in line with government policy - that’s to say, new community and regional services are developed - evidence of the effects these changes might have on the quality and cost-effectiveness of care for patients is embryonic and mixed.

While there is evidence which shows that patients who receive their operation in hospitals performing high volumes of that particular surgical procedure are more likely to survive the operation and to recover fully afterwards, more work needs to be done on examining the effects of transporting someone for a longer time prior to giving them treatment - particularly in emergencies. The claim that it is more cost-effective to deliver care in community, rather than hospital, settings has also yet to be decisively proven. Some early studies have found that procedures performed by GPs rather than hospital doctors in outpatient appointments cost more, rather than less, than if they were performed in hospitals.

Research has also found that community based urgent care services such as minor injury units do get used, but don’t bring down the number of patients attending the local A&E. This too has cost implications for the service.

A convincing case for change requires more detailed evidence on the effect reconfigurations will have on the quality and cost of patient care and greater transparency at a local level on why changes are being made and how they fit into a future vision of the organisation of services.

The government launched its first real attempt at winning clinicians’ and managers’ hearts and minds in December 2006 with the publication of two reports from the national directors for emergency access and heart disease and stroke services making the case for centralising some hospital services.

Following a year where financial deficits dominated the headlines, convincing the public that these changes aren’t just about cost cutting may prove to be an up-hill struggle.